Acute emergencies in Children are relatively rare. However, when they do occur, they are usually treated in a general practice setting rather than in a specialized children's practice or hospital, and the child's care is usually administered by paramedics, physicians, nurses and pharmacists, most of whom have little experience with the complex demands of ordering, preparing or administering drugs acutely to children. Adults' medications are standardized and frequently come in “amps” that allow immediate accurate dosing, administering pediatric drugs require multiple layers of complex, error prone calculations where misplacing a decimal point can lead to fatal, 10-fold errors (so-called “death by decimal point”). Despite the relative infrequency of acute emergencies in children, adverse drug events happen to children three times as often as to adults. Simulated studies demonstrate that when under pressure, nurses can commit errors 25% of the time when making IV drug calculations for children and errors are often only caught 20% of the time. Even the most sophisticated emergency care providers can feel uncomfortable when treating life-threatening emergencies in children. They know what to do, but they are afraid of making mistakes because of size and age-related variables. As a result, emergency healthcare providers are forced not to act or to delay needed treatment in order to check and recheck appropriate treatments so as to avoid doing harm. Hospitals have a critical need to reduce errors and treatment time in emergency pediatric care. Dosing calculations for children are notoriously error-prone.
The very process of medication administration to children under even normal circumstances is complex. First, the dose itself must be calculated based on the weight of the child, which can vary from 500 gms for neonatal infants to several hundred kilograms for older children. Each drug dose is calculated by formulas, typically expressed in mgs/kg/dose per day. Once the dose is calculated in mgs, it must be delivered in mLs of various concentrations which represent the ordered dose. In addition and further complicating the issue, a given drug may have multiple doses for different treatments. For example, Diazepam is a drug that is given to stop seizure activity in a dose of 0.2 mg/kg, but is also given to sedate a child in a different dose of 0.1 mg/kg. Once the dose is ordered for the correct treatment, a nurse would look at the concentration of the drug in the vial and set up a ratio to determine the correct volume that represents the dose ordered.
Once that volume is determined the nurse needs to know, or lookup, whether the drug needs additional dilution prior to administration. For instance, a drug such as amiodarone given for acute cardiac arrhythmias can lead to a dangerous blockage if not sufficiently diluted or if pushed too fast through the line. Other drugs can be administered without dilution, but the rate of administration varies from drug to drug. Also, the amount of fluid used to further dilute the drug can vary with the size of the child as well.
Nurses that treat adults tend to know this information because the doses tend to be standardized and acute emergencies are treated in adults on a regular basis. This is not the case with pediatric emergencies outside of pediatric ICUs and some very busy pediatric emergency departments. Even there, rare emergencies requiring special treatments such as very high potassium level in a child with renal failure and in cardiac arrest, or administering a complicated infusion such as an alprostadil to a neonate with a critical heart lesion, are still rare occurrences. Not only must these drugs be given error free, but time is of the essence. Finally, it is important that the steps leading to the correct preparation and administration of a drug are transparent to all members of the team so that errors can be recognized immediately and corrected.
A particular concern is the correct administration of continuous infusions to children. These drugs are ordered in micrograms per kilograms per minute. Until recently, a single formula utilizing a child's weight was utilized to calculate how to prepare the infusion. Recent regulations now prohibit the use of this formula in hospitals so that standard concentrations need to be utilized. Also, it is not enough to merely set the infusion at a rate that provides the proper dose, but it is also critical that the dose given is not so small that an infusion pump cannot be used to administer the dose, or too large a volume for the size of the child. Because of these issues, complex software systems have been designed to determine the concentrations to be carried in the pharmacy for a large number of standardized infusions. The standard concentrations are stored in the pharmacy so that they are already prepared beforehand. Unfortunately, certain drugs cannot be mixed in advanced. For instance, a rarely administered infusion of nor-epinephrine may be need at the bedside of a child in shock and must be mixed and delivered immediately and in real time. A pharmacist receiving an order for this drug, (if there is a pharmacist there) would be expected to be familiar with the preparation administration information for adults, but may have never mixed the particular drug for a child. Although a software system may be available in one of their pharmacy programs, it may still take a pharmacist additional time to locate and verify the proper administration. Then, even if this computer program is a simple one, the pharmacist would still need to determine exactly how to enter the information to calculate how to mix the drug. It would not be unusual for this process to take an hour in a community hospital, especially at night when there may be less help available. Once the drip has been mixed, it must be delivered to the bedside. At this point, it may not be clear to those at the bedside that it was mixed correctly and the medication is typically just administered without knowing how it was mixed or whether the calculations are correct. This is exacerbated by the fact that transport teams from children's hospitals almost always throw away the infusions that are mixed at a community hospital and remix them themselves prior to transfer.
There have been many attempts to impact these issues with various types of technologies and software solutions. Many physicians carry PDAs or smart phones that access the proper doses of medications for various indications. Even these systems require that the formula then be calculated to get the exact dose. Even if there is a calculator function in the program, it usually requires data entry to set the weight and also the drug itself needs to be found. Once this process is done, the physician can call out the dose to be given. However it is not clear to the nurse administering the dose that it was ordered correctly. A recent study determined that a nurse is not likely to recognize 80% of ten-fold errors for drugs that are not commonly given to children. Even if the dose is correct, the nurse would then need to calculate the volume in milliliters that represented that dose. In practice, this calculation is often done by hand, on the bed sheet, or on a paper towel. Once the calculation is complete, it is still not always clear to another nurse checking the dose that it was done correctly. It is also common for nurses not to know exactly how rapidly a dose must be given, whether the dose needs further dilution, and if so, exactly how much diluents are needed, all of which also change with the size of the child. To answer these questions, nursing references should be checked prior to administration, but these resources are typically not available at the bedside and if accessed, tends to be encyclopedia in scope. It takes time to find the correct medication, and takes additional time to look up in a book or scroll down in a software system to find the relevant facts. All of these safeguards take additional time and are typically not done when time is of the essence.
There is clearly a need to simplify and standardize this process to improve care and reduce medical errors for acute medication administration in children. Data entry should be minimized or eliminated entirely because it is error prone, takes time and is not transparent to others in the team. Also, even the simplest software system takes time to get oriented on how to enter data correctly. This again, takes critical time and can be quite challenging when dealing with a life threatening emergency in a child.